Provider Demographics
NPI:1881774750
Name:PORTALES, CHARLES JOSEPH (DDS)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:JOSEPH
Last Name:PORTALES
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 WEDGEWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-1349
Mailing Address - Country:US
Mailing Address - Phone:936-441-6079
Mailing Address - Fax:936-756-6902
Practice Address - Street 1:2101 MAUREL DRIVE
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304
Practice Address - Country:US
Practice Address - Phone:936-494-0200
Practice Address - Fax:936-494-2189
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX190181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice